• Health Brigade Ryan White Referral Form

    This form is HIPAA compliant. You must send all required documentation along with the referral form to submit. The form will not let you submit without everything we need to process your referral. Please allow 2 business days for us to process your referral.
  • Section A: Type of Referral

    EFA only: You have a client at your agency who needs a one time rental/utility/hotel stay and are requesting payment assistance from Health Brigade. Full Client Referral: You have a client who does not currently have a RW case manager in the Richmond area who needs our full scope of services.
  • Section B: Client's General Information

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    Pick a Date
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    Pick a Date
  • Section C: Financial Request Information

    Applicant name must be on the lease or bill when requesting assistance.
  • Rental Assistance Information

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  • Browse Files
    Cancel of
  • Utility Assistance Information

  • Browse Files
    Cancel of
  • Section D: Status Verification + Eligibility Docs

  • Browse Files
    Cancel of
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    Pick a Date
  • Browse Files
    Cancel of
  • Browse Files
    Cancel of
  • Browse Files
    Cancel of
  • Browse Files
    Cancel of
  • Section E: Referring Agency Information

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  • Clear
  • Should be Empty: